Management of dissociate disorders prof. fareed minhas


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Management of dissociate disorders prof. fareed minhas

  1. 1. MANAGEMENT OF DISSOCIATIVE DISORDERS FAREED MINHAS Professor of Psychiatry HEAD, Institute of Psychiatry Rawalpindi Medical College Rawalpindi
  2. 2. NEUROTIC, STRESS RELATED AND SOMATOFORM DISORDERS FAREED MINHAS Professor of Psychiatry HEAD, Institute of Psychiatry Rawalpindi Medical College Rawalpindi
  3. 3. INTRODUCTION  Disorders here grouped due to association with - concept of neurosis - psychological causation  NEUROSIS : when the person experiencing the symptoms of mental disorder retains insight into his condition ( in touch with reality)  This block in ICD-10 includes : anxiety disorders, obsessive-compulsive disorders, dissociative disorders, somatoform disorders and reactions to severe stress/ adjustment disorders
  4. 4. PERCENTAGE OF MAJOR DIAGNOSTIC CATEGORIES DURING FOUR YEARS IN IOP Journal of CPSP (2001) Fig.3 Percentage of major diagnostic categories. overall% Males Females 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Scizophr Depressi Bipolar Mania Drug Personal Depende ity OCD Conversi enia on on overall% 8.40% 37% 11.40% 4.80% 10.60% 1.50% 1.43% 4.80% Males 5.70% 18% 4.15% 2.90% 10.60% 0.92% 0.95% 0.60% Females 2.70% 19% 7.20% 1.90% 0% 0.66% 1.90% 4.20%
  5. 5. ANXIETY DISORDERS • Abnormal states in which the most striking features are mental and physical symptoms of anxiety not caused by organic brain disease or other psychiatric disorder Generalized Anxiety Disorder Phobic Anxiety Disorder Unvarying and persistent anxiety Intermittent; arising in special circumstances Panic Disorder Intermittent but unrelated to particular circumstances
  6. 6. Generalized Anxiety Disorders The symptoms of generalized anxiety disorder include:  Psychological- Fearful anticipation; irritability; sensitivity to noise; restlessness, poor concentration, worrying thoughts Physical- Gastrointestinal: Dry mouth-difficulty in swallowing-epigastric discomfort -excessive wind-loose motions Respiratory: Constriction in chest-difficulty inhaling-overbreathing Cardiovascular: Palpitations-discomfort in chest-awareness of missed beats
  7. 7. Generalized Anxiety Disorders (contd.) Genitourinary: Frequent/Urgent micturition-Failure of erection-menstrual discomfortamenorrhoea Neuromuscular: Tremor-prickling sensationstinnitus-dizziness-headache-aching muscles  Sleep disturbances- Insomnia; night terrors  Other symptoms- Depression; obsessions; depersonalization Differential Diagnosis : DEPRESSIVE DISORDER SCHIZOPHRENIA PRESENILE/SENILE DEMENTIA PHYSICAL ILLNESS (Thyrotoxicosis -Pheochromocytoma-Hypoglycemia)
  8. 8. Aetiology of GAD Stressful events Genetic causes Personality Environmental influences Treatment Counseling Cognitive Behavior Treatments (anxiety management training) Drug therapy (benzodiazepines; tricyclic antidepressants and beta-blockers)
  9. 9. OBSESSIVE-COMPULSIVE DISORDERS(Contd.)  Differential Diagnosis: GENERALIZED ANXIETY PANIC DISORDER PHOBIC DISORDER DEPRESSIVE DISORDERS SCHIZOPHRENIA ORGANIC CEREBRAL DISORDER  Aetiology : Genetics, evidence of brain disorder, abnormal serotinin levels and environment  Treatment- Counseling; drugs(anxiolytics short-term; tricyclic antidepressant long-term or an SSRI); behavior therapy; psychotherapy and psychosurgery
  10. 10. Phobic Anxiety Disorders  Same core symptoms as in GAD but they occur in special circumstances. The patient is free from anxiety rest of the time. 2 features characteristic are: - person avoids these situations - anticipatory anxiety  Phobic syndromes fall into 3 categories mostly: - Simple phobia - Social phobia - Agoraphobia Mostly the treatment here is psychological (cognitive behavior therapy) however drugs (antidepressants and benzodiazepines) are also added
  11. 11. Phobic Anxiety Disorders(contd.)    Simple Phobia – the person is inappropriately anxious in presence of one or more particular objects or situation. Eg. Arachnophobia (spider phobia) acrophobia (phobia of height) phobia of flying phobia of illness Social Phobia – inappropriate anxiety is experienced in situations in which the person is observed and could be criticized. Eg. Phobias of excretion Phobias of vomiting Agoraphobia – patients are anxious when they are away from home, in crowds and situations they can’t leave easily from.
  12. 12. Panic Disorder  Panic disorder is episodic paroxysmal anxiety characterised by recurrent attacks of severe anxiety which are not related to any situation and unpredictable  Symptoms of a ‘panic attack’ : - Shortness of breath and smothering sensations Choking Palpitations and accelerated heart rate Chest discomfort or pain Sweating Dizziness, unsteady feelings or faintness Nausea or abdominal distress
  13. 13. Panic Disorder(contd.)  Depersonalization or derealization Numbness or tingling sensations Flushes or chills Trembling or shaking Fear of dying Fears of going crazy or doing something uncontrolled The aetiology is based on 3 hypothesis: - Biochemical (endogenous anxiety) - Hyperventilation - Cognitive hypothesis  - Treatment - Benzodiazepines and antidepressants (TCAs/SSRIs) - Rebreathing into a shopping bag
  14. 14. OBSESSIVE-COMPULSIVE DISORDERS  Characterized by obsessional thinking, compulsive behavior, varying degrees of anxiety, depression and depersonalization  Main features maybe: - Obsessional Obsessional Obsessional Obsessional Obsessional Obsessional thoughts/images ruminations/doubts impulses rituals phobias slowness
  15. 15. DISSOCIATIVE DISORDERS  Dissociative [conversion] disorders involve partial or complete loss of the normal integration between the memories of the past, awareness of identity and immediate sensations, and control of bodily movements  Level of consciousness about the episode may vary and is difficult to assess  Several forms of dissociation are seen: Dissociative amnesia: sudden loss of memory [usually short-term] which is not due to concurrent organic disease such as epilepsy, multiple schlerosis 
  16. 16. DISSOCIATIVE DISORDERS(Contd.)  Dissociative pseudodementia: disorder with extensive abnormalities of memory and behavior that suggest generalized intellectual impairment. Simple tests are answered wrong though in a way strongly suggesting that the correct answer is in the patient’s mind  Dissociative fugue: is a state of amnesia alongwith a purposeful journey to a place out of daily range during which self-care and basic interaction is maintained  Dissociative stupor: the patient is motionless, mute and not responsive to stimulation in the absence of any physical or psychiatric finding and presence of a recent stress factor
  17. 17. DISSOCIATIVE DISORDERS(Contd.)  Trance and possession disorders : there is temporary loss of both personal identity and full awareness of surroundings. Focus of attention is narrowed to few aspects of environment. The person repeats movements, adopts postures or repeats utterances  Dissociative identity disorder : multiple personality disorder where the person switches between two personalities without being aware of it  Ganser’s Syndrome : presence of ‘approximate answers’ to questions for intellectual functioning; psychogenic physical symptoms; hallucinations and clouding of consciousness
  18. 18. DISSOCIATIVE DISORDERS(Contd.)  Dissociative disorders of movement and sensation : there is a degree of physical disability and loss of usually cutaneous sensations against all physical evidence  Dissociative motor disorders : loss of ability to move part or whole of the limb or exaggerated shaking/trembling of one or more extremities or whole body  Dissociative convulsions : pseudoseizures. They resemble epileptic fits but tongue-bite, fall and urinary incontinence are rare[almost absent]  Dissociative anaesthesia or sensory loss
  19. 19. Follow up studies Slator(1965)National Hospital for Nervous disease. 85 patients followed up for 9 years       60 % Organic disease 17 % had serious psychiatric disease 13 % had lasting personality disorder 10% had acute psychogenic reaction The diagnosis of hysteria as a dangerous myth. “Not only a delusion but also a snare”
  20. 20. The survival of hysteria, A. Lewis(1975) 98 patients suffering from Hysteria, Maudsley hospital, 7-12 years      26 - diagnosis was retained 54 - well and working 11 - other psychiatric disorders 7 - died, one by suicide “a though old word like hysteria, dies very hard. It tends to outlive its obituarists”
  21. 21. Faith Healers diagnosis      Saya Jinn possession Churail possession Tawiz Dar      Spirit infestation Evil eye Amal Jhalla / Jhally Jadoo
  22. 22. Etiology    Psychoanalytic terms- primarily a defense mechanism, withdrawal from a painful stimuli Premorbid personality and Mood disorders Stressors and Psychosocial factorsmarital, financial, occupational, warrelated stressors
  23. 23. DISSOCIATIVE DISORDERS(Contd.)  The treatment is focused on elimination of factors reinforcing the symptoms and encouragement of normal behavior.  Other ways of treatment resorted to: - abreaction - dynamic psychotherapy  DEPERSONALIZATION DISORDER is a separate class characterised by an unpleasant state of perception in which external objects or parts of body are experienced as unreal/remote/automized.
  24. 24. THANK YOU References: - OXFORD TEXTBOOK OF PSYCHIATRY(Third Edition) - ICD-10 (Clinical and Diagnostic Guidelines)